A & A case reports
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The Bispectral Index™ monitor, an electroencephalographic-derived parameter, can quantify hepatic encephalopathy cerebral function recovery and differentiate between West Haven grades 1 to 4. I report a very peculiar "plateau" phenomenon of 3 clear distinct plateaus of stepwise albumin dialysis Bispectral Index hepatic encephalopathy recovery during an 8-hour Molecular Adsorbent Recirculating System™ (MARS™) liver-assist extracorporeal detoxification, manifesting in conjunction with 3 West Haven grade recoveries. In the patients, I observed recovery of cerebral function after hepatic encephalopathy as a series of plateaus with abrupt transitions between the plateaus, rather than the gradual recovery I anticipated.
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Monitoring of cerebral perfusion by near-infrared spectroscopy estimates regional cerebral oxygen saturation (rSO2). We present a case in which, before clamping the left carotid artery during an endarterectomy, the right and left rSO2 measurements were 72% and 74%, respectively. Within 15 seconds of clamping the external carotid artery, the left rSO2 decreased by 8%, yielding right and left rSO2 measurements of 70% and 66%, respectively. ⋯ The internal carotid artery was clamped 1 minute later, whereas the external carotid remained clamped. No electroencephalogram changes were observed. The rSO2 measurements demonstrate that the value of this cerebral oximetry is not determined solely from internal carotid blood flow and can be significantly affected by the external carotid.
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Vallecular cysts, largely asymptomatic in adults, are typically described only on incidental discovery during laryngoscopy, where they may present a challenge in airway management. The current literature is limited to case reports despite the potential for life-threatening complications. ⋯ A literature review of eligible case reports was conducted, demonstrating an association between incidental vallecular cysts and difficult bag-mask ventilation and laryngoscopy with intraoperative otolaryngology consultation and intervention being common. Anesthetic management recommendations are thus presented, highlighting any conflicts with current difficult airway algorithms.
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Accidental inhalation of powder is a potential problem for infants. The clinical effects of inhaling powder depend on the powder contents, degree of aspiration, and the child's underlying systemic response. We present a case of accidental inhalation of rice starch powder in a 17-month-old girl, which led to severe acute respiratory distress syndrome responsive to conventional treatment, ultimately requiring venous-venous extracorporeal membrane oxygenation.
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As the population ages, geriatric patients with preexisting cardiac disease are presenting for noncardiac surgery in escalating numbers. The decision to proceed with surgery in such patients often is multifactorial. ⋯ However, both patients died postoperatively because of their comorbidities. Although published guidelines are sparse, we hope this report will increase awareness and discussion about caring for geriatric patients with severe aortic stenosis.